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# Ceftriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin with broad-spectrum bactericidal activity. It has a long half-life allowing once-daily dosing. Highly protein-bound; penetrates well into CSF.
## Primary Indications
- Community-acquired pneumonia
- Meningitis (including *N. meningitidis*, *S. pneumoniae*)
- Sepsis of unknown source
- Gonorrhea (uncomplicated)
- Lyme disease (neurologic or late)
- Intra-abdominal infections (with metronidazole)
- Acute bacterial otitis media, sinusitis
- Skin and soft tissue infections
- Osteomyelitis, septic arthritis
## Adult Dosing
- **Most infections**: 1–2 g IV/IM once daily.
- **Meningitis**: 2 g IV every 12 hours.
- **Uncomplicated gonorrhea**: 500 mg IM single dose (with azithromycin if chlamydia not ruled out).
- **Severe/life-threatening**: Up to 4 g daily (e.g., 2 g q12h).
- **Maximum**: 4 g/day (higher doses not recommended due to biliary sludging risk).
## Pediatric Dosing
- **Infants/children (≥28 days)**:
- Mild-moderate infection: 50 mg/kg IV/IM once daily.
- Meningitis/severe infection: 50 mg/kg IV every 12 hours (max 2 g/dose, 4 g/day).
- **Neonates (≤28 days)**:
- 50 mg/kg IV/IM once daily (caution: risk of bilirubin displacement; avoid in hyperbilirubinemia).
- **Maximum daily dose**: 2 g (except meningitis: 4 g/day).
*Note: Exact pediatric dose may vary per local meningitis protocols.*
## Dose Adjustments
- **Renal impairment**: No adjustment needed for creatinine clearance >10 mL/min. For severe impairment (CrCl <10 mL/min) or hemodialysis: max dose 2 g/day.
- **Hepatic impairment**: No adjustment unless combined severe renal/hepatic dysfunction → reduce dose.
- **Obesity**: Use actual body weight; no specific adjustment beyond standard max.
## Contraindications
- Hypersensitivity to ceftriaxone or any cephalosporin.
- Neonates with hyperbilirubinemia (risk of bilirubin encephalopathy).
- Do not co-administer calcium-containing IV solutions (e.g., Ringer’s) within 48 hours of ceftriaxone in neonates due to risk of precipitation; caution in other ages.
- Galactose intolerance (injectable contains galactose as excipient — check formulation).
## Adverse Effects
- **Common**: Diarrhea, nausea, rash, eosinophilia.
- **Serious**:
- Biliary pseudolithiasis (sludge)/gallbladder pain (reversible).
- Hemolytic anemia (rare, monitor CBC).
- *Clostridioides difficile* infection.
- Hypoprothrombinemia (uncommon; may prolong PT/INR).
- Severe cutaneous adverse reactions (e.g., SJS).
- **Injection site**: Pain, phlebitis.
## Key Drug Interactions
- **Calcium-containing IV solutions** → precipitation risk (especially neonates).
- **Warfarin** → increased INR (monitor).
- **Aminoglycosides** → additive nephrotoxicity (monitor renal function).
- **Probenecid** → increases ceftriaxone levels (usually not clinically significant).
## Monitoring
- Baseline and periodic CBC, renal function, LFTs (especially with prolonged therapy).
- For meningitis: repeat CSF cultures 24–48 h.
- Signs of hypersensitivity, diarrhea, bleeding.
- In neonates: Bilirubin levels, avoid concomitant calcium.
## Clinical Pearls
- Do not use intravenous calcium within 48 hours of ceftriaxone in neonates; in older patients, avoid simultaneous Y-site infusion with calcium but sequential administration is generally safe.
- Ceftriaxone is compatible with most fluids except those containing calcium (e.g., lactated Ringer’s). Reconstitute in NS or D5W.
- Biliary pseudolithiasis can mimic cholecystitis; ultrasound often normal. Usually resolves after discontinuation.
- For penicillin-allergic patients, cross-reactivity risk is low (~1–3%) but caution if history of immediate hypersensitivity.
- Ceftriaxone can safely be given IM (dilute with 1% lidocaine to reduce pain).
*This information is for reference only. Consult up-to-date prescribing guidelines, institutional protocols, and product monograph for complete safety information. Verify dosing, contraindications, and drug interactions before use.*
